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Search results for "United States Federal Government"

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Web Resource > Multi-use Website

AHRQ Safety Program for Improving Surgical Care and Recovery.

Rockville, MD: Agency for Healthcare Research and Quality.

Patients are vulnerable to harm after surgery. This program used methods from the Comprehensive Unit-based Safety Program to help hospitals integrate best practices into all stages of surgery to ensure safe recovery. Targeted areas of improvement include safety culture development, teamwork skills, and partnering with patients.

Audiovisual

Patient Safety Huddle.

VA National Center for Patient Safety.

The Department of Veterans Affairs consistently contributes to innovation and improvement efforts in patient safety. This podcast series offers short interviews with experts in the field that explore topics such as the VA National Center for Patient Safety leadership development program and a checklist for use in mental health facilities.

Web Resource > Government Resource

National Healthcare Safety Network.

Centers for Disease Control and Prevention.

Health care–associated infection is a persistent patient safety problem. This website provides resources related to a national health care–associated infection and blood safety error monitoring program that allows organizations to identify areas of weakness and track the impact of improvements.

Audiovisual > Audiovisual Presentation

Presenting TeamSTEPPS in the Perioperative Setting.

TeamSTEPPS Webinar Series. Agency for Healthcare Research and Quality. May 10, 2017; 1:00–2:00 PM (Eastern).

TeamSTEPPS is a process to enhance communication and teamwork in health care. This webinar will offer insights on implementing TeamSTEPPS in a large health system to improve perioperative practice. The session will highlight developing leadership as program champions, creating learning materials, and monitoring as tactics for sustaining improvements. This is part of a monthly series of educational modules on TeamSTEPPS.

Tools/Toolkit > Government Resource

Toolkit To Improve Safety in Ambulatory Surgery Centers.

Agency for Healthcare Research and Quality: Rockville, MD.

Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws from AHRQ's Comprehensive Unit-based Safety Program to help ambulatory surgical center teams develop communication and teamwork skills to reduce infections and other iatrogenic harms.

Book/Report

Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families.

Rockville, MD: Agency for Healthcare Research and Quality; April 2017.

Patient engagement in the process of care is important to improve safety in primary care. This guide includes case studies and highlights handoffs, teach-back, tools to prepare patients for appointments, and brown-bag medication management as strategies to encourage patients and caregivers to participate in safety.

Audiovisual > Audiovisual Presentation

A National Web Conference on Improving Health IT Safety Through the Use of Natural Language Processing to Improve Accuracy of EHR Documentation.

Agency for Healthcare Research and Quality. February 7, 2017.

Incomplete clinical notes create potential for treatment errors. This webinar discussed voice-generated electronic records as a strategy to augment clinical documentation and highlight natural language processing technologies as a component of this strategy.

Book/Report

Examining the Copy and Paste Function in the Use of Electronic Health Records.

Lowry SZ, Ramaiah M, Prettyman SS, et al. Gaithersburg, MD: National Institute of Standards and Technology, United States Department of Commerce; January 19, 2017. NIST Interagency/Internal Report (NISTIR)-8166.

Copying and pasting information in electronic health records can introduce risks. This report discusses a human factors study of the phenomenon to determine how the practice affects information distribution. The authors conclude that the problem does exist, describe its impact on situational awareness, and provide recommendations to improve safety associated with the copy-and-paste function.

Press Release/Announcement

Implantable infusion pumps in the magnetic resonance (MR) environment: FDA safety communication—important safety precautions.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2017.

Hazards in the magnetic resonance imaging environment can result in patient harm. This announcement raises awareness of inaccuracies and disruptions that may affect the safety of patients with implantable infusion devices who undergo an MRI exam. The statement recommends that patients inform their care team and carry an implant card with information about the implanted device to prevent these problems.

Journal Article > Government Resource

Increases in drug and opioid overdose deaths—United States, 2000–2015.

  • Classic

Rudd RA, Seth P, David F, Scholl L. MMWR Morb Mortal Wkly Rep. 2016;65:1445-1452.

Opioid medications are frequently associated with adverse drug events in inpatient and outpatient settings. This surveillance report from the Centers for Disease Control and Prevention demonstrated that the magnitude of patient harm from opioid use is growing rapidly. Opioid overdose deaths are increasing each year, through 2015, and current rates are the highest ever recorded. The types of opioids most commonly involved in overdose deaths are natural and semisynthetic opioids, which are often prescribed as pain relievers. The authors suggest that the adoption of new prescribing guidelines and more widespread use of the opioid reversal agent naloxone will help address this growing epidemic. An earlier version of this article included data through 2014. A previous WebM&M commentary described a fatal opioid overdose.

Newspaper/Magazine Article

Analysis of reported drug interactions: a recipe for harm to patients.

Grissinger M. PA-PSRS Patient Saf Advis. December 2016;13:137-148.

Drawing from reports of medication errors submitted over a 7-year period to the Pennsylvania Patient Safety Authority, this analysis found that common problems included drug incompatibility and drug–drug interaction. The article cautions against relying on drug ordering alerts as the sole strategy for preventing potentially harmful prescribing.

Book/Report

Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014.

Weiss AJ, Elixhauser A, Barrett ML, Steiner CA, Bailey MK, O'Malley L. HCUP Statistical Brief #219. Rockville, MD: Agency for Healthcare Research and Quality; December 2016.

Opioids are known to be high-risk medications, and their misuse is an increasingly recognized patient safety problem. This data analysis from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project delineates trends in opioid-related hospitalizations by state between 2005 and 2014. Both hospital stays and emergency department visits related to opioids have been increasing every year, paralleling trends in opioid overdose deaths. There was substantial variation across states, and the overall rate of opioid-related inpatient stays was 225 per 100,000 population for 2014. These data underscore the need to improve the safety of opioid use to prevent morbidity and mortality.

Book/Report

Concurrent and Overlapping Surgeries: Additional Measures Warranted.

US Senate Finance Committee. December 6, 2016.

The practice of scheduling concurrent surgeries has raised concerns about increased risks of surgeon distraction, procedure delay, and insufficient expertise available in the operating room. This United States Senate report summarizes findings of an inquiry that assessed insights from 17 hospitals regarding concurrent and overlapping surgical policies. Areas of concern identified by the investigation include a lack of available data on the patient outcomes associated with the practice and need for specific billing requirements.

Grant > Government Resource

Improving Patient Safety Through Learning Laboratories.

Rockville, MD: Agency for Healthcare Research and Quality; December 2016.

Collaborative strategies can enable individuals and organizations to learn from each other to support patient safety improvement. This fact sheet summarizes 13 projects launched through Agency for Healthcare Research and Quality funding designed for rapid deployment through team-focused learning laboratories to test and apply systems engineering approaches to improve safety in health care.

Tools/Toolkit > Government Resource

Turn the Tide Rx.

United States Office of the Surgeon General.

Large-scale and individualized strategies are needed to address opioid misuse. This website provides resources related to a national initiative to improve opioid prescribing practices by obtaining physician commitment to adhere to guidelines and screening methods.

Audiovisual > Audiovisual Presentation

Using Just Culture to Improve Results on the AHRQ Hospital Survey on Patient Safety Culture.

Agency for Healthcare Research and Quality. November 9, 2016.

A just culture balances organizational context with appropriate accountability after an error. This webinar discussed how organizations can implement just culture principles to improve their results on the Hospital Survey on Patient Safety Culture.

Book/Report

Nursing Home Antimicrobial Stewardship Guide.

Rockville, MD: Agency for Healthcare Research and Quality; October 2016.

Antimicrobial stewardship is one strategy to reduce health care–associated infections in a variety of settings. This guide provides detailed instructions and four adaptable toolkits to establish antimicrobial stewardship programs in nursing homes.

Press Release/Announcement

Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics.

Federal Register. Washington, DC: Office of Disease Prevention and Health Promotion, US Department of Health and Human Services. October 20, 2016;81:72594-72595.

National attention has focused on efforts to address adverse drug events. This call for comments seeks insights regarding revisions to a 2014 action plan that highlighted how to reduce adverse drug events associated with anticoagulants, diabetes agents, and opioids. These proposed updates involve measures to apply in both the inpatient and outpatient environments to track adverse drug events. The opportunity to submit written comments is now closed.

Web Resource > Multi-use Website

Improving Diagnostic Accuracy Project 2016–2017.

Washington, DC: National Quality Forum; October 2016.

The Improving Diagnosis in Health Care report provided recommendations to help achieve safe, reliable diagnosis. This website provides the information about a project that has convened an expert panel to identify and develop new measures to help address weaknesses in testing and tracking diagnostic accuracy. The program is currently accepting comments regarding the program framework. The submission deadline is July 12, 2017.

Legislation/Regulation > Government Resource

ONC Health IT Certification Program: Enhanced Oversight and Accountability.

Federal Register. Washington, DC: Office of the National Coordinator for Health Information Technology, Department of Health and Human Services. 2016;81:72404-72471.

Requirements are needed to manage risks associated with health information technology systems. This final rule provides a framework for government review of technologies certified by the ONC Health IT Certification Program. The rule also covers certification guidance for testing laboratories. The regulations go into effect December 19, 2016.

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